1.11/ Malnutrition and the Older Adult - Part 1

INTRO: Hello, and welcome to Clinical Nutrition Notes, a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition. Brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals for educational purposes. I’m your host Bethany Hopkins, medical affairs manager with Nestlé Health Science.

Hopkins: Today we’ll be talking with Dr. José Morais, about malnutrition in the older adult. Dr. Morais is an associate professor of medicine at McGill University, and director of the division of geriatric medicine at McGill University, McGill University Health Centre, and the Jewish General Hospital. Dr. Morais is also associate director of the Quebec network for research on aging. His research interests include protein metabolism and requirements in the older adult, nutrition and functional status. Dr. Morais has more than 100 original publications, most of them in high impact journals in the fields of aging, nutrition and metabolism. Thank you for joining us Dr. Morais. In your practice as a geriatrician, you work with many older adults who may have nutrition related concerns. Today we’ll focus on the issue of malnutrition in the older adult and the association of malnutrition with frailty. To begin, as a point of clarification, when we speak about the older adult, what age range do you consider to be an older adult?

Dr. Morais: The definition of an older adult is a conventional one, anyone above 65. But in our practice, we consider those older adults, are those above 75 years of age and with no end to the extreme advanced age. So 75 and above is the typical older person we see in our practice as a geriatrician.

Hopkins: Ok, thank you for clarifying, so we’ll have that age range in our mind as we continue this conversation. Coming back to our focus of this podcast, specifically on malnutrition, Dr. Morais can you define what malnutrition means for you as a clinician?

Dr. Morais: Yes, well, malnutrition is a general term, as more precise term is under-nutrition, and so it is a state of under-nutrition that has impact on one’s health. We see that from different perspectives. Persons who are malnourished, it not only affects their immune system and the capacity to defend themselves against infections but also they are less capable of performing tissue repair when there is injuries or surgeries. There is a significant amount of body composition changes regarding the fat mass, but also muscle mass, and as a consequence they have less energy, they feel tired, they have weaknesses, they have decreased performance. This is a manifestation of a state of under-nutrition/malnutrition in older people.

Hopkins: So as you’re describing the fatigue, the changes that you’re seeing it really sort of leads me into where I was planning on going next, and getting you to discuss how malnutrition typically presents in the older adult, and I guess you’ve already lead into that already. Are there any other comments you have Dr. Morais in terms of how you see this typically presenting in the older adults that you’re working with?

Dr. Morais: You know there are many risk factors that contribute to that state of under-nutrition, but when the person is malnourished we do observe their decreased fat reserves and muscle with this increased fatigue. The lethargy or apathy it manifests and in fact they start losing interest and pursuit in life so it affects not only physical, but the morale, it can even contribute to the decrease in their cognitive capacity. In their memories, and abilities, intellectual abilities. We do see that with advanced age. It is quite typical that an older person who is malnourished looks even older than the stated age, and this should be addressed because malnutrition is something that is amendable to be corrected, with appropriate intervention. First, we need to recognize it, and then intervene.

Hopkins: Yes, an important comment, and I know we’ll be talking about that a little more later on. You know, something that we can do something about. It’s really important to be able to be as proactive as possible I guess and recognize things as early as possible.

Dr. Morais: It’s so important, the recognition. We tend sometimes to take the older person’s appearance and physical performance as part of aging and it is not. It’s because they are malnourished to start with. It often happens without necessarily an acute illness, just simply because of a lack of intake and then it is overlooked as a problem.

Hopkins: Yes, and that’s a really great point, and it’s something that we hear about in a lot of different areas, that sometimes things are expected as a consequence of aging when in fact, they’re not necessarily that, and there’s something we can do about it. When you’re thinking about the older adult, what are the prevalence rates of malnutrition that you’re seeing?

Dr. Morais: We tend to divide the population into different categories, they have different prevalence's. If you look at a very functional healthy older adult the prevalence of malnutrition is probably 5%, but those who are homebound, those who are frail, that prevalence increases steeply to reach 30-40% of the homebound elderly. And the reason for that is risk factors. If you go into those who are in long-term care facilities, it’s 50% of them. In the acute ward of the hospital, be it in surgery, or medicine, the prevalence of an older person with malnutrition reaches incredibly high numbers of 60 even 70%, depending on the tools used etc., but it’s extremely highly prevalent.

Hopkins: And some variability as you mentioned across care settings versus the independent older adult living at home compared to the person who may be socially isolated and homebound, and then as you move into the other care settings whether it be acute care or long-term care, we’d expect to see prevalence rates rise given the individuals who are living in those settings and why they’re there.

Dr. Morais: This leads us to consider what are the risk factors that leads to malnutrition and under-nutrition state because there is reasons and these who are homebound, living in long-term care, or frequently hospitalized is a group of frail older individuals who carries a large disease burden, who have mobility issues. These are risk factors as you’ve just mentioned. We usually think in the medial world that they are malnourished, because necessarily they are having GI problems, obstruction, or pains and a lot of active inflammation with diarrhea, but it is not often the case in older adults. The reasons for that are many times psychological, because they are isolated, because there is socio-economical problems, regarding not only income, because our country is somehow protected, but because of mobility, the ability to shop, lack of interaction during mealtime because they’re isolated and not to account on the prevalence of depression/anxiety. And then there are some physiological/pathological conditions regarding their dental state. The fact that there are some sensory changes as one ages with changes in taste and smell. Then the number of chronic diseases when one doesn’t have a controlled condition, it’s congestive heart failure, or chronic bronchitis UPT. You’re appetite is suppressed, anorexia is very present, and this is a common experience because whenever we catch a cold, we don’t feel like eating too much. So individuals with chronic diseases they have decreased appetite. We need to control the diseases well, and try to overcome all of the socio-economical and psychological barriers.

Hopkins: So there can be really a large number of factors at play that place an older adult at risk for malnutrition certainly. One thing that I wanted to you to take a moment to comment on as well Dr. Morais, was around frailty. This issue of frailty in the older adult, as you’d be well aware of, and had been involved in, has really received considerable attention from clinicians and researchers in recent years and malnutrition has been associated with frailty in the older adult. Can you briefly describe for us what frailty is and the connection that we’re seeing between frailty and malnutrition?

Dr. Morais: Yes, I mean, frailty is the condition of decreased physiological organ reserve, that is beyond what we expect for age alone. So the individual is working with a maximum of their capacity, no reserves, and when they face any stress, an infection, a fall, surgery, then they really decompensate and it is known that one of the mechanisms through which we progress from what is usual aging into a frail aging, one of the causes is decreased food intake, under-nutrition, from any condition that we just mentioned, a few risk factors etc., it is a cascade of effects because there are implications or impact on body comp., on decreased muscle, decreased bone density, and weaknesses. Then it triggers a vicious circle in which there is less food intake, less energy intake, less energy expenditure, and further decreases in essential nutrients to maintain one’s health and necessary vitality. This then contributes to the state of frailty. That’s the way I see it because when an older person is eating very little and there is some weaknesses taking place, it takes such an effort to mobilize that it increases further the muscle atrophy, the weaknesses and they cannot come out of it without appropriate intervention that includes food and exercise.

Hopkins: Given that connection with malnutrition, and nutrition intake and frailty, is it fair to say then that by recognizing and potentially providing some sort of intervention from a malnutrition perspective we may be able to, for some individuals, have an impact on that frailty trajectory or pathway?

Dr. Morais: Yes, I mean, there is different degrees of severity of frailty, but certainly at the earlier stages, it is always possible to bring the individual to a better health state, and less frailty and especially at a mild frailty level, there’s a chance to bring the person to a more normal healthy state. So nutrition is something one can offer and contribute to decrease the frailty and give persons more capacity, autonomy, make a more normal living. But the problem is sometimes that our attitudes in which we don’t recognize the malnutrition status and we attribute everything to old age.

Hopkins: This really leads into my last question I’d like to ask you in this episode, and you started talking about the consequences of malnutrition for individuals in terms of their quality of life, their functional status, their health and well-being. It can also have an impact on families and caregivers and even broader impacts on things like healthcare resources. In your practice, what are some of the consequences of malnutrition that you’re seeing Dr. Morais?

Dr. Morais: People don’t think about it, but a lot of these reports of older persons being weak and having repetitive falls, behind there is many states of malnutrition. So malnutrition contributes to weaknesses and falls, to decreased autonomy of an older person, usually or frequently, a malnourished person is also someone who is mildly dehydrated, and they contribute to orthostatic hypertension, blood pressure that drops upon standing contributes to falls. And and when someone has recurrent falls, for safety issues, then we very quickly propose for them to be put into an institution, placed in long-term care institution. So certainly malnutrition contributes to that. Once you are malnourished and you catch something, an infection etc., and you are prone to having infections, then at the hospital, they have a prolonged stay, compared to non-malnourished people, more infections. Those who are so weak, they are bed-bound, they develop more easily decubitus ulcers. In severe states of under-nutrition the increased risk of mortality because of complications while they’re hospitalized. It’s a known fact that malnutrition increases mortality. But before such things occur, which is the worst outcome obviously, there is also a lot of morbidity. A lot of things that we could prevent just by correcting the nutrition status that is impaired in the process.

Hopkins: Yes, and outcomes that make a real difference for the individual themselves. You know, being able to do the things they enjoy doing. Some of those functional aspects that you mentioned are so important and that we can see changes fairly early on. Dr. Morais I’d like to thank you for sharing your experience related to malnutrition, which as you’ve mentioned is a real concern for a number of older adults and something that we need to identify earlier and fortunately we may be able to do something about for some people. I’d like to continue this conversation on our next podcast and we’ll have you address strategies to manage malnutrition during that conversation. Thank you Dr. Morais for joining us and I’d like to thank all of our listeners.